U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Printing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2250 Mail: Stop SSOP, Washington, DC 20402–0001

91–118 PDF 2004

S. HRG. 108–248

AGEISM IN HEALTH CARE:

ARE OUR NATION’S SENIORS RECEIVING PROPER

ORAL HEALTH CARE?

FORUM

BEFORE THE

SPECIAL COMMITTEE ON AGING 

UNITED STATES SENATE

ONE HUNDRED EIGHTH CONGRESS

FIRST SESSION

WASHINGTON, DC

SEPTEMBER 22, 2003

Serial No. 108–22

Printed for the use of the Special Committee on Aging

(

SPECIAL COMMITTEE ON AGING 

LARRY CRAIG, Idaho, Chairman 

RICHARD SHELBY, Alabama 

SUSAN COLLINS, Maine 

MIKE ENZI, Wyoming 

GORDON SMITH, Oregon 

JAMES M. TALENT, Missouri 

PETER G. FITZGERALD, Illinois 

ORRIN G. HATCH, Utah 

ELIZABETH DOLE, North Carolina 

TED STEVENS, Alaska 

RICK SANTORUM, Pennsylvania 

JOHN B. BREAUX, Louisiana, Ranking 

Member 

HARRY REID, Nevada 

HERB KOHL, Wisconsin 

JAMES M. JEFFORDS, Vermont 

RUSSELL D. FEINGOLD, Wisconsin 

RON WYDEN, Oregon 

BLANCHE L. LINCOLN, Arkansas 

EVAN BAYH, Indiana 

THOMAS R. CARPER, Delaware 

DEBBIE STABENOW, Michigan 

LUPE WISSEL, Staff Director 

MICHELLE EASTON, Ranking Member Staff Director 

(II) 

C O N T E N T S 

Page 

Opening Statement of Senator John Breaux ......................................................... 1

PANEL OF WITNESSES

Vice Admiral Richard H. Carmona, Surgeon General, U.S. Department of 

Health and Human Services, Washington, DC ................................................. 3

Greg J. Folse, Lafayette, LA ................................................................................... 19

APPENDIX

Testimony of Daniel Perry, Executive Director, Alliance for Aging Research .... 61

Statement of Dr. Robert Collins, American Association for Dental Research 

(AADR) .................................................................................................................. 66

Statement by Teresa Dolan, American Association of Public Health Dentistry 72

Statement submitted by James Harrell, American Dental Association .............. 78

Statement of Dr. Paula K. Friedman, Professor and Associate Dean of Administration, Boston University Goldman School of Dental Medicine, and President American Dental Education Association ................................................... 83

Written statement of Karen Sealander, American Dental Hygienists’ Association ........................................................................................................................ 98

Testimony of Jonathan Musher, MD, on behalf of the American Health Care 

Association ............................................................................................................ 124

Statement of Dr. Robert Barsley, Oral Health America ...................................... 127

Statement of Robert J. Klaus, President and CEO, Oral Health America ......... 132

Testimony of Dr. Paul Glassman, Associate Dean, Co-Director Center for 

Oral Health for People with Special Needs, University of the Pacific School 

of Denstitry, President, Special Care Dentistry ................................................ 137

Statement submitted by The Apple Tree Dental Model ....................................... 143

Testimony of Kim Volk, President and CEO, Delta Dental Plans Association .. 150

(III) 

(1)

FORUM ON AGEISM IN HEALTH CARE: ARE 

OUR NATION’S SENIORS RECEIVING PROPER ORAL HEALTH CARE? 

MONDAY, SEPTEMBER 22, 2003 

U.S. SENATE, 

SPECIAL COMMITTEE ON AGING, 

Washington, DC. 

The Forum convened, pursuant to notice, at 2:05 p.m., in room 

SD–628, Dirksen Senate Office Building, Hon. John Breaux, presiding. 

Present: Senator Breaux. 

OPENING STATEMENT OF SENATOR JOHN BREAUX 

Senator BREAUX. If everybody would please find a seat, we can 

begin our afternoon session, and I will do so by welcoming everyone 

to what is really a forum this afternoon; it is not a formal Aging 

Committee hearing, but it is an opportunity for all of us who are 

interested in the question of health care for our Nation’s seniors to 

focus in on one particular aspect of our Nation’s health concerns 

and particularly dealing with our Nation’s older Americans, and 

that is the whole question of proper oral health care, dental care, 

for our Nation’s senior citizens. 

So I would like to welcome everyone to this session this afternoon, and I want to thank the Chairman of the Aging Committee, 

Senator Craig, for his cooperation and support and assistance for 

allowing us to meet and have this discussion. 

This afternoon we will focus on the question of whether older 

Americans are receiving proper oral health care. I think the purpose is really threefold—first, to define the oral health issues that 

are facing our Nation’s seniors today, and second, to try to develop 

and discuss some potential solutions to the problems that exist; 

and third, to alert Americans about the opportunities they have to 

help improve health care, particularly oral health care, for America’s elderly. 

Although there have clearly been dramatic improvements in oral 

health care during the last 50 years, profound disparities continue 

to exist for those without the knowledge, the resources, or the capability to achieve good-quality oral health care. 

This certainly includes our poor and vulnerable elderly and disabled adults, and poor oral health care causes suffering to millions 

of Americans and obviously particularly to our most vulnerable 

population. 

2

Twenty-three percent of the 65- to 74-year-olds have severe periodontal or gum disease. The percentage of risk increases, of course, 

as people age. People at the lowest socioeconomic levels have even 

more severe periodontal disease. Oral and pharyngeal cancers are 

diagnosed in about 30,000 Americans annually, and 8,000 die from 

these diseases every year, which are primarily diagnosed in the elderly, and their prognosis is very poor. 

Fewer than 2 out of every 10 older Americans are covered by private dental insurance. Uninsured Americans with severe oral disease often end up in hospital emergency rooms, where the problem 

is addressed with painkillers and/or tooth extractions, both of 

which are obviously only a temporary fix, wasting millions of taxpayer dollars every year. 

Recent research has further highlighted the results of poor oral 

health care. Studies have shown a connection between chronic oral 

infections and heart and lung disease and stroke and diabetes and 

premature birth. Infections resulting from oral infections place individuals at serious risk of death. Infectious diseases of the mouth 

left untreated can cause undue pain and suffering and poor quality 

of life, and even death. 

Clearly, all Americans need to be aware of the need for good oral 

health. However, our emphasis today is on grappling with how best 

to ensure that our older Americans receive proper oral health care. 

It is my hope that this forum will accentuate the importance of oral 

health. 

Thanks to the generous support of Oral Health America, we are 

releasing a report today entitled ‘‘A State of Decay: Oral Health of 

Older Americans.’’ As you can see from the charts behind me, Oral 

Health America surveyed all 50 States and the District of Columbia on the extent of the oral health care services for Medicaid 

adults. As a part of this study, a report card was developed that 

reflects predominantly failing grades in all jurisdictions, giving the 

United States a score of ‘‘D’’ as our national average. It is very 

alarming, considering the severe health consequences and resulting 

cost of poor oral health care. 

I thank each and every one of you for being with us and for your 

participation and look forward to hearing from you as we discuss 

this issue. 

I would first like to welcome the Surgeon General, who is a surgeon but not a general, but he is an admiral, and we are very 

pleased to welcome Vice Admiral Richard Carmona, who is our 

Surgeon General. Vice Admiral Carmona was sworn in as the 17th 

Surgeon General of the United States Public Health Service in 

August 2002. He is a decorated veteran and graduate of the University of California Medical School. Dr. Carmona has published 

extensively and received numerous awards, decorations, and local 

and national recognition for his achievements. We thank him for 

participating and for his support. 

I would also like to introduce Dr. Greg Folse, who is a practicing 

dentist from Lafayette, in my State of Louisiana. He was instrumental in drawing my attention in the beginning to the critical 

issues surrounding oral health of the elderly. He has a mobile 

geriatric dental practice and also works with the American Dental 

Association and Special Care Dentistry to improve oral access for 

3

special needs patients. He is really very passionate about caring for 

the oral health of the elderly and carries out that mission every 

day of his life. 

I have seen the slide presentation that Greg will make to us this 

afternoon. It is most impressive in highlighting the serious nature 

of the problem that we face as a Nation. 

I would also like to say thanks to all of the organizations represented here this afternoon. I am pleased to introduce these organizations and the representatives who are here today. Your biographies are all included in our official record, and I will simply recognize you for the sake of brevity: 

From the Alliance for Aging Research, Dan Perry. Dan, thank 

you for being with us; from the American Association for Dental 

Research, Dr. Robert Collins; from the American Association of 

Public Health Dentistry, Dr. Teresa Dolan; from the American 

Dental Association, Dr. James Harrell; from the American Dental 

Education Association, Dr. Paula Friedman; from the American 

Dental Hygienists’ Association, Karen Sealander; from the American Health Care Association, Dr. Jonathan Musher; the CMMSHHS chief dental officer, Dr. Conan Davis; from Louisiana State 

Dental Medicaid Services, Dr. Robert Barsley; from Oral Health 

America—thank you for the good work—Dr. Robert Klaus; from 

Special Care Dentistry, Dr. Paul Glassman. 

Thank you all. 

I would like to also introduce Janet Heinrich, who is with GAO, 

the Government Accounting Office’s Director of Health Care and 

Public Health Issues. She has put together and led many of the 

health studies that we have utilized, both in the Finance Committee and in our committee on elderly issues, for the U.S. Senate 

and for the Congress, and we appreciate once again her doing the 

work. We are going to ask her to moderate if I have to leave some 

of the discussion, Janet, if that would be all right with you. 

Ms. HEINRICH. Yes. 

Senator BREAUX. Our format will be to first hear from our Surgeon General, Dr. Carmona. If you would go ahead and lead us off, 

we would appreciate hearing from you, and then we will go to Dr. 

Folse and his slide presentation. 

Mr. Surgeon General, we are delighted to have you with us. 

STATEMENT OF VICE ADMIRAL RICHARD H. CARMONA, SURGEON GENERAL, U.S. DEPARTMENT OF HEALTH AND HUMAN 

SERVICES, WASHINGTON, DC 

Dr. CARMONA. Thank you, Senator. It is nice to be here. Thank 

you for taking the leadership in this very important area. 

My name is Richard Carmona. I am the United States Surgeon 

General, and as an American, I want to take this opportunity to 

thank all of you for the service that you have provided to the Nation in keeping this very important issue on the forefront. 

I have had the honor of working with many of you during my 

first year as Surgeon General and look forward to strengthening 

our partnerships to improve the health and well-being of all Americans. 

Senator, you have been a leader in addressing the health needs 

of America in general and its seniors, and I thank you so much for 

4

continuing to take the lead in those issues. It was a pleasure participating with Senator Craig, another leader, just recently in a 

Montana Health Summit, and Senator Burns, who also understand 

the value of public health and keeping our citizens healthy. 

Today I welcome the opportunity to talk with this committee 

about the oral health of America’s seniors. While oral health is tremendously important, I am sure I do not have to tell you that it 

does not receive much attention. For that reason, I appreciate the 

focus of this forum, especially in the context of a holistic approach 

to disease prevention. 

Poor oral health adversely affects all aspects of life. Kids cannot 

learn in school if they are in pain. Adults miss work due to dental 

pain and tooth and gum decay. Twenty-two percent of adults report 

having some oral pain in the past 6 months. Oral and pharyngeal 

cancers, primarily found in the elderly, are diagnosed in about 

30,000 Americans annually. Tragically, 8,000 Americans die from 

these diseases each year. 

‘‘Oral Health in America,’’ a report of the Surgeon General, recognizes that such oral health is essential to general well-being and 

that the oral health of America’s seniors is today an acute problem. 

The facts are staggering. About 30 percent of individuals 65 years 

and older have lost all their teeth. The rate of oral and pharyngeal 

cancers is higher among seniors than for any other age group. 

Americans 65 years and older are seven times more likely to be diagnosed with oral cancer than younger individuals. 

The vast majority of payment for dental services is out-of-pocket 

for older people, with only rare exceptions. Medicare does not cover 

the cost of oral health services. This results in compromised access 

for our seniors. While 61 percent of the general population reports 

having a dental visit in the past year, only 45 percent of seniors 

75 years and older report seeing a dental professional in that same 

time period. 

A number of HHS programs focus on oral health needs of seniors. HRSA’s oral health program is increasing access to oral health 

care through its 843 health center grantees. Seventy-two percent of 

these centers offer preventive dental care. Also, NIH’s National Institute of Dental Health of Dental and Craniofacial Research reports many clinical trials related to the oral health of seniors. 

In addition, CDC’s division of oral health supports oral health 

projects in predominantly poor, ethnically diverse communities. 

These projects include: mobilizing community health workers to improve oral health practices in rural Alabama; setting up an oral 

health training program for nurses who care for homebound seniors 

in Harlem, which is my old neighborhood; and in Washington 

State, training seniors to be oral health educators for children, 

which improves the health of the kids and the seniors. 

As you know, in April of this year, I released a National Call to 

Action to Promote Oral Health. The Call to Action is a guide for 

our efforts to improve oral health. It outlines five action areas. 

First, we need to change the perceptions of oral health. We can 

no longer afford to have Americans believe that oral health is separate from general health and well-being. Improving health literacy 

is key to improving America’s oral health. 

5

Second is to replicate effective programs and proven efforts. Best 

practices in oral health must be recognized and replicated in every 

State. 

Third is to build the science base. Biomedical and behavioral research is transforming our knowledge of prevention, diagnosis, and 

treatment of oral diseases. This knowledge must be turned into action. 

Fourth is to increase oral health workforce diversity, capacity, 

and flexibility. Women and minorities are under represented in the 

dental profession. We must encourage diversity and use culturally 

competent messages to eliminate disparities in oral health. 

Fifth and finally is to increase collaborations. Disease prevention 

and health promotion campaigns that affect oral health, such as 

proper brushing and flossing and regular checkups, as well as tobacco control and nutrition counseling, can lead to improved oral 

health for all Americans. 

The prevention message that President Bush, Secretary Thompson and I have been emphasizing is applicable to ensuring good 

oral health. For example, there are simple steps that any person 

can take to prevent dental diseases. They are: proper brushing and 

flossing; use of fluoride rinse or toothpaste; regular visits to the 

dentist; healthy eating; limiting alcohol use and avoiding tobacco. 

In particular, tobacco use, whether cigarettes, cigar, or smokeless 

tobacco, frequently results in oral cancers. Most people, even many 

health professionals, do not know that smoking causes over 50 percent of the periodontal disease in the United States. 

We need to get this information to the public and to health professionals. Again, it is an issue of health literacy. It is a battle in 

many areas of public health that I find, increasing health literacy 

so that people understand the good science that we have already 

available and we are not using it fully. 

In closing, I will add that today must be a day of change. Today 

must be a day when our work is a catalyst for better oral health. 

I thank you for many efforts on behalf of seniors, and I promise to 

work with you to improve the health and well-being of all Americans. 

With that, I will end my oral remarks. I would ask to be able 

to submit my entire written statement into the record, and I would 

also be happy to answer any questions, Senator. 

Thank you very much. 

Senator BREAUX. Thank you, Dr. Carmona. 

I understand that you need to catch a plane, so we are not going 

to keep you too long. I am going to let you be excused whenever 

you feel that you have to. 

Dr. CARMONA. Thank you, sir. 

Senator BREAUX. But I want to thank you for your participation. 

I think that a lot of people do not understand the serious nature 

of the problem, and I think that you as the Surgeon General obviously have the capacity to highlight the serious nature of oral 

health care for seniors at a time when many Americans seem to 

be more concerned about the color of their teeth; they want to 

make them whiter, and there are more and more products for 

whiter teeth and how you can get them to be brighter and brighter. 

There are many older Americans who are suffering very severe 

6

health problems, not because of lack of white teeth but because of 

severe infections and other problems that they have. 

So in your capacity as Surgeon General, I think it is important 

that you make the statement that you made today and continue to 

try to highlight this as a particular problem and a particular concern. 

So we thank you for being with us and hope you can continue 

helping to educate the American public about this very serious 

problem. 

You may be excused whenever you have to go because you have 

told me that you need to catch a plane for a trip. 

Dr. CARMONA. Thank you, Senator. 

I would just add that, as I said when we released the report, you 

have my full commitment as does the American public in keeping 

this area of oral health on the forefront. 

Thank you, sir. 

Senator BREAUX. Thank you, Admiral. 

[The prepared statement of Dr. Carmona follows:]

7


91118.001
8


91118.002
9


91118.003
10


91118.004
11


91118.005
12


91118.006
13


91118.007
14


91118.008
15


91118.009
16


91118.010
17


91118.011
18


91118.012
19

Senator BREAUX. Now let us ask Greg to make his slide presentation, and then we will be able to begin the dialog that I hope we 

can get on trying to find out what we need to be doing. 

Dr. Folse. 

STATEMENT OF GREG J. FOLSE, LAFAYETTE, LA 

Dr. FOLSE. I want to thank you very much, Senator Breaux, for 

bringing us all together today. 

You talked about the whitening—I think the color that my patients would really like to have their teeth is ‘‘some.’’ Unfortunately, that is where we are. 

That is one of the things that Louisiana happens to do well, actually. We have a good denture program for our elderly, but we do 

not pay for a lot of other things. 

I also want to thank Dr. Carmona in his absence for his call to 

action. I think it is already affecting lives. But we have a long way 

to go. 

Ageism and oral health—are our Nation’s seniors receiving proper oral health care? The answer is resoundingly no—they are not 

receiving it right now when you look across the board. 

The Surgeon General’s report in 2000 called it ‘‘a silent epidemic’’ for our elderly. I think that when you really look at it, and you see 

the patients that I see—and let me back up a little bit. I have a 

mobile geriatric practice, and I go to nursing homes every day; I 

am in there day in and day out. When you see what I see, it is not 

silent—it screams. It screams for us to take action on the issue. 

This is Miss Sylvia. I am going to introduce you today to a few 

patients of mine, and if you cannot see, please get up and move 

around; that is fine with me. Ms. Sylvia was the mother of a nursing home administrator. She had just arrived at the facility. She 

was poor. She had been in the community. You will notice her hair 

is pretty; she has it all combed. She was really trying to take care 

of herself. She has lipstick and rouge, and everything was Cadillacing for her—except when you looked in her mouth. 

She did not have access to oral health services. She did not go 

and have her teeth cleaned. She had gum disease. She had broken 

teeth. She had abscesses in the back of her mouth. She had infection. 

We cannot stand for this. Her daughter cared dearly for her and 

did not really realize that this was going on. 

This is Mr. Joe, an old man in a facility—I work in facilities all 

day, and I love nursing facilities. It is not that he was there, but 

there is a great burden of disease when these patients get into 

nursing facilities, and that burden is difficult for us to deal with. 

He had a tooth, which you can see right her, that they asked me 

to take a look at. When I did, they told me his story. He was a 

grumpy guy who would sit in his wheelchair and literally run the 

wheelchair into your ankles. He was ornery and hated everybody, 

and nobody liked him. 

Well, when I looked in his mouth, under his lip was this huge 

squamous cell carcinoma. This guy thought he was dying; his face 

was rotting off. This cannot be. Had he had one dental evaluation, 

one cleaning, while he was getting older, someone would have 

picked this up. 

20

We did radiation therapy, this became a little scar, and the guy 

did very well. He started going to bingo and became a good part 

of the facility. 

Who are these patients? When I look at the country, I had this 

term introduced to me not too long ago—the ‘‘aged, blind, and disabled.’’ If we can think about our seniors and our vulnerable adult 

population and use this term, we will be ahead of the game, because this term is defined in Social Security law, so it is a great 

place to hang our access hat. 

This gentleman, Mr. Charles, is a good representative of ‘‘aged, 

blind, and disabled.’’ He is all three of them. He was in a facility, 

and I told him 2 months ago, ‘‘I am going to Washington. I am 

going to try to get some help for your teeth.’’ He was all happy, and 

he gave me this kind of convoluted smile that you can see here. He 

was happy about it. 

He allowed me to take photographs of his mouth, and today he 

sits in this facility with no access to oral health care with these 

teeth. This is how he eats every day. He has broken teeth, he has 

gum disease, he has abscesses. These are teeth that are broken off 

at the gum line, for those of you who do not know. 

When I told him that I was going to Washington just to talk, he 

thought I was going to take his teeth out that day, and he got 

angry; and when he did, this was the face he made, and I just 

quickly took a shot of it. I am with you, Mr. Charles; I feel the 

same way. Let us do something. 

How many of them are there? In my written testimony, I have 

some actual numbers of disabled adults, but we all know that the 

number of seniors in our country is going through the roof. 

Just like Miss Marsha—these slides I took a month ago—6 

months ago, she had an abscess for this little tooth, right here. 

This tooth needed extraction 6 months ago. There is no access in 

our State, along with other States—I will tell you how many in a 

little while. I put her on antibiotics. Someone else put her on antibiotics a month later, and someone else again a month after that. 

A $100 extraction would have taken care of this. The fourth time 

she got infected, she got an MRSA infection, which is a staph infection that is resistant to antibiotics. She had to go in the hospital—

and that is where these pictures were taken—so that they could do 

a little surgical procedure, a drainage here. During the procedure, 

she was septic, and her heart stopped beating, so she went into the 

ICU for 4 days. One hundred dollars for an extraction, $30,000 for 

a surgery and ICU stay. It does not make a lot of sense, besides 

the suffering that this lady had to go through. 

As a practitioner, it kills me, because they sit and they rot under 

my care, and I hate it. Guys like me all across the country see the 

oral health of our seniors is neglected. 

The report from the Surgeon General said there are many disparities, and there are. The elderly take the brunt of it. If you have 

money, you can get care—until you get medically or functionally 

disabled, or until you get institutionalized or you spend all of your 

money. Then you start losing that access that we all have as functional adults. 

Within the ‘‘age, blind, and disabled’’—and I realize this is not 

quite as on-point—but we have mentally retarded adults in our 

21

country who sit in facilities or who sit at home with no access to 

oral health care. This is a sin that our mentally retarded do not 

have access. 

This poor gentleman sits—he is losing his teeth, he has gum disease, he has abscesses—and there is nothing I can do about it. 

There are hundreds and thousands of them across the country like 

this. We have to do something on a national level. 

I wish the Surgeon General was here for this. We need a statement from him saying that oral health services are medically necessary for this vulnerable population. I think that is going to be a 

key to the advocacy or the push to get services. 

It goes on and on, people. I saw this guy, and 2 years before I 

took this photograph, these four teeth were in perfect shape; he 

had a $900 partial hooked to it that he was eating with. Two years 

later, after a stroke, he has gum disease, he bleeds every time he 

eats—and no access to care. 

This is the old tooth in the lung, another $100 extraction that turned into a $40,000 or $50,000 surgical procedure and hospital 

stay with all these complications. A loose tooth—she rolled over, hit 

her mouth on the bed rail, and it went into her lung. 

This is a birth mark. Miss Mary had this birth mark all her life. 

But what I want you to look at are her eyes. Do you see that? Two 

weeks before I took these photographs, Miss Mary was walking and 

talking. She developed a dental abscess. Had she had any access 

over the last few years of her life, they would have caught something. 

Miss Mary, you can see, is swollen here; actually, she has some 

purulent drainage down on her bib. This was in the front of her 

mouth. I would think that this tumor would have been caught by 

somebody had we had access to oral health for an aged, blind, and 

disabled adult. She could have gone somewhere. 

Miss Mary died from the infection that got into this tumor. They 

could not take care of it. Seven days after I took these photographs, 

she passed away and really has solidly put the need for what we 

are doing here today in me. 

My wife will kill me, but I offer my services to all of you as we 

go through this process of getting access for these patients to help 

in any way I can. 

What benefits are available? The Surgeon General talked about 

it. There is virtually nothing until you get down to Medicaid—virtually no Medicare, private insurance, applied income laws. Medicaid has optional programs for every State. States can individually 

choose whether they want dental services or not. 

This is what our country looks like—blue is a B; New York gets 

a B—as far as Medicaid services go. The green States are C’s. The 

yellow States are D’s, and the red States are F’s. I got to pick the 

colors, too—it is pus yellow and blood red—and I am not going to 

apologize for it. It is a sin. 

We have 45 States with a D or an F, and when you look at the 

service reimbursements—and all of this is included in the Oral 

Health Report Card from Oral Health America, which I thank you 

guys for doing; it was great to be a part of that—when you look 

at the service reimbursements for the providers out there, all 

States except one get a D or an F. 

22

So when I couple the D-minus grade for Medicaid with the vulnerability of the ‘‘aged, blind, and disabled,’’ I give our country an 

F on how we are doing. 

Do we get it yet? There is nothing out there for these adults. The 

system of optional Medicaid oral health benefits is not working. We 

have in essence designated treatment of pain, pus, infection, and 

swelling as ‘‘optional,’’ and it does not make sense, and I know you 

all agree with me. 

So nationally, unfortunately, we have no infrastructure for oral 

health for ‘‘aged, blind, and disabled.’’ We do, however, have an infrastructure for children under EPSDT, and this is where I really 

think the solution can come. I believe that if we could take the 

‘‘aged, blind, and disabled’’ who are already approved for Medicaid 

and put them into coverage under EPSDT or in a system like that, 

I really believe that that would work. 

National solutions—again, we need a bill, and I know that you 

will be open to helping us with that with the ABD patients. Within 

my testimony, I have included kind of the guts of that idea of the 

‘‘aged, blind, and disabled oral health access proposal’’; it is in my 

written testimony. I would love to see a declaration that oral 

health services are definitely medically necessary. I would like to 

see the formation of a National Oral Health Coalition for Special 

Needs Adults, and a dental director in every nursing home. 

It can be done well. This is Miss Daisy. I made these dentures 

for her when she was 103 years old. Miss Daisy lost them 4 years 

later, and I remade them. Miss Daisy wore those dentures until 

she was 112 before she passed away. She had good oral health, and 

it meant a lot to her. We can do that on a national level. 

I thank you all very much for being here, and I thank you for 

participating in this event. 

Thank you, Senator Breaux. [Applause.] 

[The prepared statement of Dr. Folse follows:]

23


91118.013
24


91118.014
25


91118.015
26


91118.016
27


91118.017
28


91118.018
29


91118.019
30


91118.020
31


91118.021
32


91118.022
33


91118.023
34

Senator BREAUX. Thank you very much, Greg. 

I met with Greg previous, and I had seen his presentation back 

in Louisiana, and it was what really got me interested in trying to 

figure out where we are as a Nation with regard to oral health care 

for seniors. 

Let me just start—and I want you all to enter into discussion, 

not me—I would rather just sit and listen—but Greg, you made a 

statement that Louisiana has a good program. 

Dr. FOLSE. For denture care only. 

Senator BREAUX. Oh, for denture care. Explain the difference between oral health care and just denture care that we have in Louisiana. 

Dr. FOLSE. Oral health care would include extractions, would include all the preventive services, exams, x-rays, getting teeth 

cleaned, gum disease treatment, fillings. That is an oral health 

care program. 

What we do is only the prosthetic side, which is a piece and an 

important piece of oral health, but we make dentures. We do not 

take out bad teeth to give you dentures, but we do provide dentures for patients whose teeth are already gone. 

Senator BREAUX. That is really interesting; we are after the fact. 

Dr. FOLSE. The program was started years ago when most of our 

elders—in our State, probably 65, 70 percent of our elders had no 

teeth. Now I am seeing only about 40 percent; so I am seeing 60 

percent with teeth now. So back then when they started that program, a majority of the population was affected by it in a positive 

way. So it made sense back then. 

Senator BREAUX. So the State Medicaid program covers the dentures? 

Dr. FOLSE. Yes, sir, they do. 

Senator BREAUX. You are really pointing out something. Older 

citizens, like my grandparents’ generation, were just expected to 

lose their teeth and never to have all of their teeth. 

Dr. FOLSE. Exactly, yes, sir. 

Senator BREAUX. OK. The information is obviously very graphic. 

I think we have a problem, and the question is how extensive is 

the problem. Can anybody talk about that a little bit? I have seen 

Lafayette, and I have seen Louisiana, but what about the study 

that we did with oral health? 

Robert, do you want to comment on that? How did you all do the 

survey? 

Dr. KLAUS. We surveyed Medicaid dental contacts across the 

United States. I would suggest that the study results that we see 

here today are really the tip of the iceberg, that the problem is 

probably far more serious than even we would come out and say. 

Senator BREAUX. What kinds of programs do we have for oral 

health care among the States? I guess the States’ obligation would 

be under the Medicaid program for the low-income. 

Dr. KLAUS. Medicaid—but under the Medicaid program, the first 

thing to be cut when times get tough in State legislatures as they 

are now, with States facing huge deficits, is the dental benefits of 

Medicaid. Recently, Michigan cut all Medicaid benefits except for 

those that relate to emergencies. 

35

We think that this pattern is going to continue. I just heard this 

morning from people in Georgia that next year, they think they are 

going to cut back on their dental benefits for Medicaid. 

Senator BREAUX. Is the best that any State has under Medicaid 

an optional program that covers dental? 

Dr. KLAUS. Yes. They are all optional. 

Senator BREAUX. They are all optional, and many of them do not 

even have them as an option. 

Dr. KLAUS. No, many of they do not have them as an option. 

Senator BREAUX. Greg. 

Dr. FOLSE. Correct. The children’s program is not optional, but 

all programs for adults are. You get a range of different types of 

programs. Minnesota right now is doing very well with their program. There are little problems within individual programs, and as 

a whole, you have Medicaid issues nationally. But it is optional 

versus non-optional. 

So from Minnesota, which is doing well, treating a lot of nursing 

home patients and a lot of elderly across the State, it goes down 

to States with absolutely nothing, not even a denture program; so 

you have us all in the range. 

The effectiveness of those programs, though, comes in when you 

really grade it, and that is what the report card did. We cut out 

five different procedures and looked at the reimbursement rates 

and said what dentist is going to do this for these types of fees, and 

that is where we got all the D’s and F’s. It was just way below 

what is out there. 

Senator BREAUX. We sent all of you some questions, and I want 

to try to keep it focused to a certain extent. The first question is: 

What is the greatest problem that seniors face where oral health 

is concerned? 

If you are poor, the greatest problem is you do not have it. Anybody can start to comment on this. My father fortunately has access to his employer’s retirement health program that covers dental 

care. He probably also has enough money that if he did not have 

that insurance, he could afford to go to a dentist and pay the bill. 

But that is probably not the situation for most Americans. Let 

us talk about that. 

Paula. 

Dr. FRIEDMAN. Senator, thank you for this opportunity to comment. I think that this is a tremendously important issue, and I 

would suggest that we consider, in additional to the financial 

means to access care, the dearth of qualified providers. One of the 

reasons that there is a problem certainly is financial, but another 

level of problem is that there are so very few qualified people 

trained in geriatric dentistry. A few of them happen to be seated 

around this table. But I would ask you to think about how many 

dentists are trained annually to provide the special training to provide care to senior citizens. I am not going to put you on the spot, 

but I am sure you would not imagine. Under HRSA—and we are 

grateful for the support that HRSA provides toward training geriatric physicians and dentists—less than 10 dentists a year for the 

entire country are trained in providing special services to this frail 

elderly population with medically compromised, complex medical 

conditions. 

36

So I certainly recognize the financial aspect, no question about 

that, but I am sure that my friend and colleague Dr. Folse would 

agree with me that access is also a function of having qualified providers. 

Dr. FOLSE. Without a doubt. It is kind of what comes first, the 

chicken or the egg, because I have had 3 years of extra training 

so that I could take literally a 50 percent pay cut over my colleagues. So what is going to come first? I do not think we could get 

the—you almost have to have the financial infrastructure at the 

same time. I do not care which one gets there faster. We have got 

to do both of them, and you are exactly right. 

Dr. FRIEDMAN. You certainly have to address both. I happen to 

be one of the dental directors of one of the HRSA-funded geriatric 

dentistry and medicine training programs, so I can tell you that 

there are only five to seven dentists per year in the entire country. 

Senator BREAUX. Well, we only have five medical schools, and we 

just recently picked up two more, but out of all the medical schools 

in the country, 113 or so, there are only five that offer graduate 

programs in geriatrics. It is the fastest growing segment of our population in America, and yet only five medical schools offer advanced degrees in geriatric specialties. So when you break it down 

to subspecialties of dentistry, you can understand why we only 

have 10 graduates a year. 

Yes, Mr. Harrell. 

Dr. HARRELL. I am a consultant to a nursing home, which I do 

mostly on a free basis—I take a 100 percent cut—and we have a 

Medicaid program that covers adults, although the reimbursement 

rates are extremely low, sometimes as low as 14 to 16 percent of 

cost. 

Senator BREAUX. Who has the program? 

Dr. HARRELL. North Carolina. 

Senator BREAUX. Oh, the State does—under the Medicaid program? 

Dr. HARRELL. Although we fear we are going to lose it. I think 

the only reason we came out so well this year was the one-time 

Medicaid reimbursement to the States which saved us from probably a lot of lobbying and a lot of heartache. But this is going to 

come back again next year. But it is a financial issue. As a family 

dentist, I see geriatric patients in my office on a daily basis. A lot 

of them have insurance or can afford it otherwise, or they would 

have Medicaid. But going into a nursing home facility—I serve 

three—there are no facilities, no equipment. The nurses and staff 

know very little about oral health, and most of the time you are 

doing extraction in the middle of the night with a weak flashlight 

battery, and they always feed them right before you get there. I do 

not understand that. So I know we need geriatric dentists—I am 

not underplaying that—but we need to stimulate family dentists. 

Senator BREAUX. I would think—and I am obviously not a medical doctor—but it would seem to me that the fact that we do not 

have a lot of geriatric dental specialists, it seems to me that any 

doctor of general dentistry can look at these seniors and the problems they have are no different than those of a young child who 

has not been to a dentist in 15 years of his life. I mean, a practicing dentist would be able to look at an elderly person just like 

37

he does a person who has never seen a dentist who is 20 years old 

as the same types of problems develop. There are a lot of other 

problems, particularly mental illness and others, that seem to be 

a lot different among the elderly and more difficult to recognize 

that it is a problem of aging. 

Dr. HARRELL. There are special needs patients that you cannot 

treat without some type of facilities, and in a lot of places, we do 

not have those. 

Senator BREAUX. I would bet you there is not a nursing home 

anywhere in the country that has a resident dentist. 

Dr. FOLSE. I am actually a dental director in 14 nursing homes 

now, and I am there usually a time or two a week, and we do all 

of our services. I do do some extractions and cleanings and those 

kinds of things at the facility—— Senator BREAUX. But how many other dentists do that? 

Dr. FOLSE. Not many. To build the infrastructure that we are 

going to need to get people doing those kinds of services, one of the 

things is to take away the yearly budgetary threat that we get 

from Medicaid on a State-by-State basis. That has a significant impact when you have a system built to treat vulnerable adults, but 

it is always on target. I have trouble getting other dentists to do 

that when the States pull the rug out from under us every year. 

Senator BREAUX. But what kind of compensation does a dentist 

who does what you do get? Is he reimbursed anywhere? 

Dr. FOLSE. I am reimbursed for the denture care, and a lot of the 

other stuff is donated. 

Senator BREAUX. We know these other problems are not denture 

problems; they are just gum disease problems. You are not going 

to be reimbursed zip for that. 

Dr. FOLSE. But I am not treating it, either. It is sad. I have 2,500 

patients, and 1,600 patients have cavities and gum disease under 

my watch, and they do not get treated. I put the fires out as much 

as I can. I treat the ones that the families will let me treat. But 

as a whole, having an infrastructure where guys in an office could 

get paid to see these patients and I could refer them to you would 

be great. 

Senator BREAUX. Are there any other comments from anybody? 

Dr. Barsley. 

Dr. BARSLEY. Senator Breaux, I appreciate the opportunity to be 

here today. 

I have worked with Dr. Folse over the years in Louisiana, and 

one of our problems has been I have pulled the rug out from under 

Greg more than once when our State ran out of funds; I have reduced the amount of money that we can pay to him. Fortunately 

this year, we were able to increase that amount of money, and one 

thing we thought about doing was increasing the services that were 

offered. Our problem was that the pent-up demand is so vast that 

once we increase the range of services we can offer, we have no 

way to judge how much pent-up demand there would be; if we had 

to extract just one tooth in every person in Louisiana who is Medicaid-eligible, that is one million teeth. 

Senator BREAUX. How much do we pay for dentures? 

Dr. BARSLEY. We pay roughly $1,000 in Louisiana. 

Senator BREAUX. I mean what is the total cost. 

38

Dr. BARSLEY. In Louisiana, our budget for adult services is about $4 million. 

Senator BREAUX. Four million dollars for dentures. 

Dr. BARSLEY. For dentures only and the exams that go with 

them, yes, Senator. 

Senator BREAUX. Suppose we just did not do dentures, and we used the $4 million for oral health? 

Dr. BARSLEY. That is what I am looking at. 

Dr. FOLSE. Yes. 

Senator BREAUX. Is there any prohibition—I mean, could a State 

do that if it wanted to? 

Dr. BARSLEY. Senator, we could, but I am very much afraid—in 

fact, we are discussing this very weekend adding dental care for 

adult pregnant women to help decrease low birth-weight children. 

We are estimating that adding extractions and cleaning their teeth 

will probably cost about $3 to $4 million for the 30,000 women who 

would be covered in the next year. So if we were to cover all the 

Medicaid-eligible people in Louisiana and cover a range of services 

limited just to that——

Senator BREAUX. Does anybody know if any other States just 

cover dentures? 

Dr. FOLSE. That is optional. I mean, you can cover whatever set 

of benefits you want. 

Senator BREAUX. Yes, I know, but I think it is unusual that we 

cover dentures but not oral health. 

Dr. FOLSE. Yes. 

Dr. DOLAN. Senator, the State of Florida had an adult denture 

program until about 2 years ago, and when they had Medicaid cuts, 

they eliminated that program. That is why my State is a ‘‘red’’ State on Dr. Folse’s chart, because actually, we have one of the 

highest proportions of older adults in the United States, and yet we 

do not have the ability to serve the needs of those individuals. 

Senator BREAUX. So Florida is not able to do dentures or anything else in oral health? 

Dr. DOLAN. No. In fact, I was the dental director for four nursing 

facilities in Florida as part of my teaching responsibilities at the 

University of Florida and was faced with the same frustrations 

that you face every day in that you try to do the right thing for 

these individuals, and yet there was not the public or private financing to meet the needs of the residents of these facilities. 

Dr. FOLSE. Senator, I beg your forgiveness for the interruption. 

You are talking about cost. In special care dentistry, we looked at 

the problem of including oral health for adults in Medicaid, and 

when you cover the whole population, it costs a lot of money. You 

are really in a jam. You are not able under Medicaid to carve out 

like ‘‘aged, blind, and disabled.’’

If we could carve out ‘‘aged, blind, and disabled,’’ which is the 

most vulnerable population, and cover them under Medicaid, that 

is a doable thing. We put together as part of my written testimony 

the proposal—we looked at what California spent on ‘‘aged, blind, 

and disabled’’—and they have full dental benefits there—and we 

extrapolated that out to the country, and it looked like about $1.2 

billion a year if you put those patients under the dental programs 

that are currently there. That is pretty much a max, because some 

39

of those patients are already being treated, so the ones like California would be included in that $1.2 billion, so we are already 

spending that. It would probably add from our estimation about 

$700 million a year to the country to treat ‘‘aged, blind, and disabled’’ under Medicaid. It just makes sense. 

Senator BREAUX. Would you have to drop others—aren’t children 

included? 

Dr. FOLSE. Children are covered now under Medicaid; correct. 

Senator BREAUX. You are not talking about dropping them. 

Dr. FOLSE. No. I am talking about just adding ABD adults into 

the EPSDT program that is already existing in all the States. 

Senator BREAUX. Does anybody have any thoughts about that? 

Yes, Paul? 

Dr. GLASSMAN. Paul Glassman, from Special Care Dentistry. 

Thank you for the opportunity to be here. 

Greg is referring to some data that we did collect in California, 

where the people who were in that category, adults who are ‘‘aged, 

blind, and disabled,’’ account for 33 percent of the Medicaid population in California and currently use about 20 percent of the Medicaid dollars. So that is where the numbers came from to extrapolate what it would cost nationally. California actually received a Cplus on the chart, which was one of the three highest States because of that program—although that program has been threatened and almost went away this year. Again, the one-time block 

grants to the States saved it from being removed this year. 

I also wanted to comment that—you asked earlier about data—

in the recent Surgeon General’s Report on Oral Health in America, 

it actually says in the report that one of the problems when you 

are talking about special populations is that there really is not any 

good data, and it actually talks about that in the report. 

I am president this year of Special Care Dentistry, and we have 

1,000 members, which is a small group of very dedicated people 

who spend their lives treating people who are aged, blind, and disabled, and each one of those people has a thousand stories. So 

there is no question in our minds that this is a huge problem. The 

numbers are staggering, but as Greg says, it tends to be a silent 

epidemic because the people who are suffering really do not have 

a voice to let their suffering be known. 

Senator BREAUX. Tell me again what is your situation in California. The aged, blind, and disabled constitute about 33 percent? 

Dr. GLASSMAN. We have an adult Medicaid program for dentistry, so adult Medicaid recipients are covered by dental benefits. 

Of those who are covered, about 25 percent fall into the category 

of ‘‘aged, blind, and disabled,’’ and they use about 20 percent of the 

Medicaid expenditures. 

Senator BREAUX. What does the program in California cover? 

Dr. GLASSMAN. I cover all the kinds of things that Dr. Folse was 

talking about—basic examinations, cleanings, fillings, extractions, 

treatment of infections, screening for oral cancer. It does cover dentures. Some people say that it does not cover enough, but I actually 

think it is a very good program for basic services. 

Senator BREAUX. But how did they only get a C if they cover all 

that? 

40

Dr. KLAUS. Because they missed in other major—I do not have 

the report right in front of me, Senator—but they missed in other 

major categories. Paul, you probably know those better than I do. 

Dr. GLASSMAN. I think it is actually a good program compared 

to many States in the country. It certainly has its problems, and 

I think that is where the C came from. 

Senator BREAUX. So you miss seniors who are not aged or disabled or blind; they are not covered? 

Dr. GLASSMAN. Yes, that is right. Low-income seniors are covered. 

Senator BREAUX. All low-income seniors eligible for Medicaid 

have dentistry as an option. 

Dr. GLASSMAN. Right, yes. Most people who are eligible for Medicaid gets dental benefits, right. 

Dr. FOLSE. Their low grade came from real low reimbursement 

rates. 

Senator BREAUX. Other than that, they have a good program. It 

is just a question of the reimbursement rates—because the services 

are provided. 

Dr. FOLSE. Yes. A lot of the States have full coverage is what 

they say, but when you look at the effectiveness of that coverage, 

because it is below the tenth percentile of what dentists charge, it 

is real hard to get the infrastructure. 

Senator BREAUX. That is true of everything—in the CHIP program in my State of Louisiana, we have insurance for children 

under the Medicaid program, but the reimbursement rate is so low 

that many doctors refuse to take children as patients because of 

the reimbursement rate. It is all a question of money, isn’t it? 

Dr. FOLSE. Yes. 

Senator BREAUX. Is there other discussion on this? 

Yes? 

Dr. HARRELL. I wanted to bring up the reimbursement to make 

sure you are clear. States have programs; it does not necessarily 

mean they fund those at a reimbursement level adequate enough 

for people to have access. In North Carolina, by a funny twist, the 

State was just successfully sued by a children’s advocacy group because they did not raise the fees, the reimbursement, enough to 

allow the required access. The funny thing is—not funny—but the 

nice irony is that they did it by codes, and a lot of those codes are 

also adult codes. So that is going to help our geriatric Medicaid 

population also. But just because you have children’s Medicaid or 

a Medicaid program does not necessarily mean you are providing 

access. 

Senator BREAUX. Let me understand. How many States have 

dentistry covered under the Medicaid program, regardless of the reimbursement rates? 

Dr. FOLSE. Virtually all of them. 

Senator BREAUX. So all of them do—Louisiana, too? I thought we 

just covered dentures. 

Dr. FOLSE. There are I believe eight States with no services at 

all, and this is from some data that I had about a year ago, so I 

am doing it by memory. I think we had eight with none and 22 

with either limited or emergency only, and the rest of the States 

41

had what they considered full coverage for adults. For children, everyone is required to have full coverage. 

So the heart of this would be taking ‘‘aged, blind, and disabled’’ and saying you must cover them also, and that is where ageism 

comes in to me. We have a vulnerable child population, and we 

have the same issues on a vulnerable adult population, but we do 

not have the same requirements. I would love to see that as a requirement. 

We could increase the FMAP for the States, too, the Federal 

matching dollars. If we increased that for that program, it would 

be a really nice thing that would fly politically—with a big question 

mark. 

Senator BREAUX. I’m not sure what flies politically today. 

Dr. Davis, what about CMMS? Can you comment on what we 

have been listening to here? 

Mr. Davis. The latest number that I have on the number of 

States that do provide adult dental care is 8 for full benefits, 16 

for limited benefits, 18 for emergency-only benefits, and 9 that 

have no coverage at all. Those are the current numbers right now 

on the Medicaid side. 

Senator BREAUX. Karen. 

Ms. SEALANDER. Karen Sealander with the American Dental Hygienists Association. 

While there are many inevitable declines in seniors’ health, a decline in oral health is preventable, and that is why it is such a 

tragedy to see Dr. Folse’s slides; because if seniors receive regular 

preventive services, we could prevent all of these horrible oral 

health tragedies. 

While the profession of dental hygiene was founded back in 1923 

as a school-based profession, over the years, hygienists have lost 

many outreach opportunities. One solution to the oral health care 

crisis that ADHA would like to see is increased entry points into 

the oral health care delivery system. Even seniors who have insurance, whether it is Medicaid or private insurance, often cannot get 

access to care because they cannot travel to a dental office. So we 

need to go out and reach these seniors where they are, and ADHA 

would like to see dental hygienists play an increasingly important 

role in delivering care to people where they are, whether that be 

in a nursing home or an assisted living facility. 

In many States, there are restrictive supervision requirements, 

but there are some States pioneering less restrictive requirements, 

and ADHA would like to see that encouraged. 

Presently 25 States allow hygienists to provide services in nursing homes; 12 States recognize hygienists’ ability to provide services to homebound patients; and 10 States recognize hygienists as 

Medicaid providers. ADHA would like to be part of this solution in 

a collaborative way. Dental hygienists cannot provide all oral 

health services—we need to work in conjunction with dentists—but 

hygienists would like to be able to reach more seniors with our 

services. 

Senator BREAUX. Let us talk a little bit about that. I do not want 

to get into a battle between dentists and hygienists, like we have 

done over the years with psychiatrists and psychologists and chiropractors and medical doctors, et cetera, et cetera. But there are two 

42

questions. No. 1, how much help can dental hygienists provide if 

they were involved in treatment of our elderly citizens, and No. 2, 

if they can be of help, how many of them would be available considering the shortage of dentists that we have? 

Can anybody talk to me about how much help they could be? 

Ms. SEALANDER. Senator Breaux, with respect to the historic turf 

battle, there is more than enough unmet need for all of us to play 

a significant role, so there is really no need to squabble over turf. 

With respect to the workforce issue, the number of dental hygienists in the workforce has grown steadily and is expected to increase 

by 37 percent between 2000 and 2010. Dentists, on the other hand, 

are among the five health professionals with the slowest rate of job 

growth, a 5.7 percent increase projected between 2000 and 2010. 

Right now, approximately 5,500 dental hygienists graduate each 

year and about 4,300 dentists graduate each year. Morever, dental 

hygienists are educated to care for geriatric patients; geriatric care 

is a required part of the dental hygiene accreditation standard. 

Because dental hygienists provide preventive oral health services; and do not provide restorative services, hygienists to work in 

connection with dentists, and hygienists can serve as a pipeline to 

dentists. One hygienist in Portland, OR provides services in a nursing home in an onsite dental clinic that was built with donated 

equipment. She works there one day a week, and then, one day a 

month, a dentist comes in and provides the needed restorative care. 

Dr. FOLSE. They would be an integral part of the team, and I 

think hygienists are going to be integral in the final solution of 

this; they are going to be a big part of it. 

Senator BREAUX. Anybody else? 

Paul, and then Jim. 

Dr. GLASSMAN. You are touching now on workforce issues, which 

I think are going to become a major problem. This problem that we 

are talking about now with elderly and disabled people having difficulty getting access to care is going to get worse because of workforce problems. 

It certainly is true that the number of hygienists is growing faster than the number of dentists. Dentists who are retiring now went 

to school at a time when there were 6,000 dentists a year being 

produced, and they are being replaced by today’s 4,000 graduates. 

The thing I want to point out, though, is in all of the estimates 

about how critical this workforce shortage is going to be, all those 

estimates if you look at them carefully are based on an underlying 

assumption, and that assumption is that those people who are currently left out of the oral health system who do not have access to 

oral health are going to continue not to have access to oral health. 

All the analyses on workforce are based on that assumption 

Senator BREAUX. DR. HARRELL. 

Dr. HARRELL. The American Dental Association has consistently 

studied the workforce issue, and there are some problems with 

some of the data, and it is hard to project the needs in the future. 

We recognize the value of hygienists, particularly as Greg said in 

a team concept, where the dentist does the diagnosis but the hygienists particularly are extremely valuable, I think, on the education end of this thing. 

43

I looked the other day, and there are 44 States—our policy in the 

American Dental Association is that it is sort of a States’ issue, but 

44 States have chosen to give some laxity of supervision to hygienists in nursing homes. Whether that has increased the care, I do 

not know. The only concern is that the diagnosis is done so that 

we do not just polish decay but that we really give treatment. 

Senator BREAUX. Yes. It seems to me that some of these people 

who are institutionalized, not to mention those who are not in institutions, but all those who are in assisted living facilities or nursing homes, never really have anyone look into their mouths to see 

what kind of oral health they have. A dental hygienist could certainly help identify serious problems that necessitate a dentist to 

do the extra work that may be required, but there is an awful lot 

that could be done just to help identify the problem and help with 

at least a partial solution to the problem. 

Dr. Collins. 

Dr. COLLINS. Thanks, Senator. 

Like others, I appreciate the opportunity to be here. For the moment, I would like to make three points. 

One is about the reimbursement issue, which is obviously a complex one, and you have heard a lot of different statistics about what 

is covered and what is not covered. The key issue to me is that the 

service is an optional one regardless of where you are in the United 

States, so that when times get tough, things that are optional tend 

to disappear. This is the solution that Greg is offering as an attempt to address that. 

The second point I want to make is about education and training, 

looking at alternate solutions—not necessarily training an entire 

workforce of geriatric specialists—that is probably very impractical, 

although I would certainly encourage us to have a core of them; 

certainly we need them as faculty to teach, we need them in programs where they can take referrals for the more difficult, and we 

need them to educate of general dentists in order to get treatment 

to these older patients, who yes, may have the same kind of disease, as younger patients but they also have many co-morbid conditions that make it difficult to treat them and that add special conditions that require consideration. 

In some of the material that was provided in advance of the 

hearing, it has been reported the dental schools, that have made 

considerable progress in offering didactic material—in geriatrics 

nearly all of them do now—but clinical training has lagged behind. 

I graduated from dental school in Philadelphia in 1971, and 

there was no geriatrics in my course of study; there was very little 

public health. Downstairs in a little, obscur room, there was something called a special patients’ clinic, and I had an instructor who 

by chance got me involved in that clinic, and I think it made a big 

difference in my interest in this area and in public health in general, because you got an opportunity to understand that these people had needs like everybody else, and they were eminently treatable if you had the right skills and you understood that. 

So that is definitely one of the three legs of the stool. You have 

to have practitioners who understand that whether they are dentists, whether they are auxiliaries, whether they are hygienists. 

44

The third point I want to make is in the area of research. In the 

Surgeon General’s Report, he talks about science being the lead 

and the connection for us to make progress in this area and many 

other areas in oral health. I definitely think there are many opportunities, some of them linking the reimbursement and workforce 

issues, maybe done through the universities, looking at different 

distributions of personnel and how well they can address problems, 

whether the elderly patients are in the community or they are in 

the institutional setting, because in either situation, it is not a 

matter of one size fits all. We used to make assumptions—and I 

think that is why there are so many denture programs or priority 

on dentures—that people were going to lose their teeth, and if they 

lost all of their teeth, then they were going to need dentures. Our 

other priority was kids. So we had denture programs, and we had 

basic programs for kids. 

Times have changed rapidly as dental insurance has grown. We 

have people with complex medical problems, but they also have 

complex dental problems; they are moving into old age, and suddenly, they do not have reimbursement for this care, and as they 

develop other kinds of co-morbid conditions, they have problems. 

There is a vast opportunity for us, I think, in the research arena, 

delivering care in many cases at the same time, to find solutions 

that use resources wisely—give patients what they need; do not 

give them more than what they need. 

Senator BREAUX. A good point. 

Paula. 

Dr. FRIEDMAN. Thank you, Senator. 

I wanted to point out a workforce issue agenda that is actually 

interdisciplinary, and it speaks to the need for increased education 

in oral health across all health care disciplines, and the invisibility, 

if you will, of oral health care among other health care providers. 

I brought with me for the purposes of this hearing two publications that just came out. One is a Public Policy and Aging Report 

produced and published by the Gerontological Society of America 

called ‘‘Emerging Crisis: The Geriatric Care Workforce,’’ which 

speaks about the dearth of health care providers across all health 

care professions, except that oral health is not even mentioned 

here. There is no mention of oral health in this well-respected association’s publication on the workforce crisis. 

The second one is a joint publication by the Merck Institute of 

Aging and Health, and again, the Gerontological Society of America, called ‘‘The State of Aging and Health in America,’’ which 

again does not mention oral health at all. 

So I think that when we talk about workforce issues and about 

increasing awareness of oral health as an important and critical 

component of overall health, which was mentioned by Surgeon 

Everett Koop many years ago, it is very important to not only consider the oral health professions but interdisciplinary professions 

as well. 

Senator BREAUX. That raises a question, Greg, with your slides, 

and I am sure that any State you go to, you could go to a senior 

facility and see the same problem, maybe some even worse certainly, maybe some not as bad. But why doesn’t a regular medical 

doctor when doing a normal check on an elderly American—anyVerDate 0ct 09 2002 11:50 Jan 13, 2004 Jkt 000000 PO 00000 Frm 00048 Fmt 6633 Sfmt 6633 C:\DOCS\91118.TXT SAGING1 PsN: JOYCE
45

body can look into someone’s mouth and say look, they have a dental problem. I mean, I could look in there and say this is a dental 

problem before it got to the point where it got there. You did not 

need a dentist to tell those folks in your slides that they had a 

problem long before it got to that point. 

Do doctors not notice this, or ignore it, or just do not look? 

Dr. FOLSE. I have had a lot of interaction with the American 

Medical Directors’ Association. They are the doctors who go into 

the nursing homes. I teach them about this, and I called it ‘‘the 

forehead slap’’—when you talk about it and they go, ‘‘Oh, my God— I am not even looking.’’ I see that time and time again. I call it ‘‘the 

forehead slap factor,’’ and I have it on an additional slide. 

We have a long way to go in that regard. I think, though, that 

as we gear up as I have in my area and as other dentists have 

around the country, when you gear up an oral health program, 

they start thinking about it. Then, when you have a few patients 

who have complex problems and you point it out to them, they 

start looking. But it needs to be part of the normal routine, and 

it is not right now. 

Senator BREAUX. Teresa. 

Dr. DOLAN. Senator, I had the good fortune as a recent dental 

graduate to participate in a VA fellowship training program which 

was multidisciplinary, where I worked with the nurses and physicians and physical and occupational therapists, and we learned 

from each other. That was one way of sensitizing them to oral 

health issues that they were probably never exposed to during 

their usual curricula. 

Also in the VA, they had dental operatorie in the nursing facility, 

and we provided preventive and restorative care with dental hygienists, and it was a wonderful model. 

Over time, those programs disappeared, so we had probably 

fewer than 30 trained geriatric dentists who had that experience. 

Senator BREAUX. In VA facilities? 

Dr. DOLAN. In VA facilities. Many of those VA trainees are in 

this room and have become the academic leaders in geriatric dentistry. 

When I joined the University of Florida, we had a 6-year HRSA 

training program, also multidisciplinary, with physicians, dentists, 

and other health care providers, where we learned from each other. 

Physicians learned about oral health. We learned from physicians 

about medical complications that were important in dental therapy. 

Again, those programs were severely cut in Federal budget cuts. I 

believe that now there are fewer than 10 individuals being trained 

in those programs. We no longer have a program in the State of 

Florida. 

I think models have been tried and have been successful, but 

they require commitment and resources. I think we do have a lot 

to learn from each other. If you look at the medical education curriculum right now, there are probably less than 10 total hours of 

instruction, in a good school, about oral health issues. 

So I think there are many, many areas that need to be addressed. We have had models in the past that have worked and for 

one reason or another are no longer funded and supported. 

Senator BREAUX. Yes, Dr. Musher. 

46

Dr. Musher. Senator, I am a physician. I am board-certified in 

family practice, and I am a fellowship-trained geriatrician. I am 

also a past president of the American Medical Directors’ Association, so I was happy to hear comment about that. 

One of the things that that organization has been trying to do 

is help educate our medical directors who by law have to be in 

nursing homes related to the different issues that are important in 

nursing homes, and one of them is oral care. 

But I do want to mention in my training as a fellow that I was 

trained in oral care. I reach a point, just as anyone else, where I 

would find a problem in oral care and I would need to find a dentist or an oral surgeon to help care for that problem. 

But I think we are saying two important things here. One is the 

team approach, and the second part is education. In the nursing 

homes, we have what is called the minimum dataset, and in part 

of that, we are supposed to be assessing for oral care and looking 

in our residents’ mouths, our patients’ mouths, and assessing for 

certain problems. 

I have heard a lot of people have advocate for education, and I 

think that is critical. I think we have to better educate the staff 

in the nursing homes all the way down to the CNA level what to 

look for and then how to plug that patient into the system, and I 

think they can be educated. They are with the patients every day. 

They are helping brush their teeth, taking care of their dentures, 

et cetera, et cetera, so I think that would be important. 

I think educating physicians to work with dentists and other 

health professionals is part of that. I think there are a lot of physicians who are still in nursing homes that are not as well-trained 

or feel as comfortable, if you will, looking in patients mouths. 

I also wanted to comment that, for example, a lot of the patients 

we are seeing now in the nursing homes are frail, they are demented, they are a little harder to care for in some of these ways, 

but there are some simple things besides what we have heard 

today that I struggle with every day such as xerostomia, which is 

just a dry mouth, either from medicines or just from the aging 

process, which has huge repercussions. I have had patients who 

were going to get gastric feeding tubes because they stopped eating 

because you need saliva to taste the food. My patients were not 

tasting the food, and they stopped eating. As soon as that was 

brought to my attention, I realized it was a dry mouth. 

That is something simple that anybody could hopefully recognize 

and correct. So I think it underlines again that more education is 

critical. 

I guess one side comment because I also have a private practice, 

and one of the things that has frustrated me—and maybe it gets 

to the financial issue a little bit—is that I think if there were less 

paperwork related to billing issues, maybe the health care system 

would not be as costly. 

Senator BREAUX. Thanks, Jonathan. 

Robert. 

Dr. KLAUS. It seems to me and to Oral Health America that 

there are two chapters in health history in the United States. One 

is overall health, and then there is oral health. This has contributed to the problems of oral health being perceived in almost abject 

47

isolation and what we call almost a militant indifference—and it is 

not just us. Listen to how the Frameworks Institute, a think tank 

in Washington, DC., describes the problem. ‘‘You cannot solve a problem that is not perceived to exist by the 

public. To say that this issue has not emerged in public discourse 

is to greatly understate the issue. It is invisible.’’ I would suggest 

just looking around the room—and I do not know everybody here— but we are all part of the oral health family, and the solutions to 

this problem will not be advanced, Senator, until we begin to get 

outside and get coalitions that speak to this issue as passionately 

as we do. 

Senator BREAUX. That is a good point. I have always said that 

in solving problems, first, people have to understand that there is 

a problem, and after you realize there is a problem, you can talk 

about possible solutions to the problem. The third part of any program is to convince people that these solutions are worth pursuing 

and worth investing a financial commitment to help pay for what 

you think is the right solution. 

So first, you have got to recognize that there is a problem, and 

that is what we are trying to do and to try to let more people know 

that the oral health of our Nation’s seniors is a severe problem and 

is one that can be corrected. 

Then, we have got to come up with some ideas of what should 

we be doing. Greg suggested trying to make sure we at least cover 

aged, blind, and disabled seniors. We could start in that area. 

Then, you have got to have the political wherewithal to go out 

and sell that proposal. 

So it is a three-step process. It is not rocket science, but it takes 

some commitment on the part of people. 

Somebody else had a point. Paul, first. 

Dr. GLASSMAN. Just to extend this discussion about awareness 

and are people seeing things or not seeing them or ignoring them, 

I think it is a combination of both. It certainly is a gigantic awareness problem where people look right past the mouth and sometimes do extensive medical tests, workups running to thousands of 

dollars for somebody and it turns out to be a dental problem. 

I spent 20 years working in a hospital dental clinic where that 

would happen time and time again. You would have someone who 

was in the ICU and had been there for a week and had had all 

kinds of expensive tests and then finally, in frustration, giving up 

and saying, ‘‘Let us call a dentist in,’’ and you would look, and sure 

enough, there would be a dental infection, and that was what was 

causing the problem. 

I supplied a videotape to your staff of an adult lady who was not 

verbal and mentally retarded who was admitted to a locked psychiatric facility in California at a cost of $150,000 a year to the 

State of California because she was exhibit bizarre behaviors and 

lashing out at people around here. Luckily, there was a dental hygienist in our State who was connected through a program we have 

who came in and saw her and thought maybe this was a dental 

problem. Because we have adult benefits in California for this 

group, they were able to see her, and within 24 hours after dental 

treatment, she was back to her normal behavior and back living in 

the community again. 

48

That was a pretty dramatic story. So I think we have a giant 

awareness problem, but I think we also have a giant frustration 

problem, which is imagine that you are a physician or a social 

worker or a nurse and you are in a nursing home or working with 

a group of disabled people, and you look in the mouth and you recognize there is something wrong, and you try to get someone to 

come in and see that person. How many times are you going to try? 

You dial the phone, and you call 20 dentists, and after a while, you 

give up, and you stop looking, and you stop trying to even bother 

because you know you are not going to get anyone to come in and 

see them. 

So we need awareness, and when someone does become aware, 

we need to have something that they can do that is going to work. 

Senator BREAUX. That is a very dramatic story from a cost standpoint. 

Dr. HARRELL. Senator, we appreciate you taking your time this 

afternoon, by the way. 

I want to make two points. I just participated in an Interfaces 

Conference which dealt with children’s dentistry, sponsored by the 

American Association of Pediatric Dentistry, and they had a group 

similar to this. The physicians in the group did state pretty overwhelmingly that—I think they would have caught some of the 

slides that Greg had—but especially a lot of the subtleties of oral 

health, they were not trained in. In fact, none of the doctors 

present were. I thought that was interesting. 

Second, with Dr. Folse and some of the people who are sitting 

here, we are developing an oral health assessment and survey process for nursing homes, and CMS is reviewing that right now. Basically, we would like to at least have the right questions asked, hoping to raise awareness on oral health needs. 

Senator BREAUX. Tell me about what. What are you all submitting? 

Dr. HARRELL. It is called an oral health assessment and survey. 

It is for nursing home patients, and the nursing home fills it out. 

That is being produced right now; CMS I think is reviewing it. 

Senator BREAUX. Do they do that now, or not? Is it a requirement to do that now when a patient enters into a nursing home? 

Dr. FOLSE. Yes, yes. In every nursing home chart, there is a 

health questionnaire called the MDS, and on the MDS are seven 

different oral health questions, and those questions have a lot of 

problems. 

Senator Breaux, you have been instrumental, whether you know 

it or not, in helping me to expose that at CMS. It was from some 

of the letters and correspondence that you had with CMS about 

oral health a few years back; so I had it down to thank you for 

that, actually. 

We have submitted the actual new questions that will be in 

every chart across the country, which are going to be good questions. 

Senator BREAUX. How do they differ from what the existing program requires? 

Dr. FOLSE. The existing questions had the four main diseases—

oral cancer, tooth-borne gum disease, and prosthetics—all mixed 

49

into a bunch of jumbled questions, so when you tried to answer 

one, you had to look at three different things. 

We separated out those four areas, and by separating them, we 

will be able to use some of the national data that we have about 

cavities and gum disease for the gum disease questions. 

Also, again because of your efforts at CMS, we did the National 

Surveyor Training Session about a year and a half ago, where we 

trained the nursing home inspectors. It was pretty much based on 

the MDS, and the video from that has been dispersed—there were 

a lot of responses from our facilities across the country looking at 

oral health. They got this videotape, and they looked at it because 

they wanted to know what the surveyors were going to be looking 

for. 

We are still pretty deeply involved in it, and special care dentistry has really been teaming up with ADA and CMS to have a 

real good result with that. 

Senator BREAUX. Can Mr. Davis comment on that? That survey 

will indicate the potential problem that senior has coming into a 

nursing home. 

Dr. FOLSE. Correct. 

Senator BREAUX. It does not provide any treatment, but it at 

least recognizes that there is a problem. 

Dr. FOLSE. Correct. 

Senator BREAUX. Can you comment on the use of that data? 

Mr. Davis. That data is collected on each patient, and it is actually collected in the nursing homes. It is expanded now. Dr. Folse 

spoke recently to a group that CMS participated in. It is a contracting group, and they are looking at this expansion of questions 

for a minimum dataset for dentistry. That is still under review. It 

is not finalized yet. But it is an expansion. 

Senator BREAUX. That does not do anything for the patient. It is 

just sort of let us go to the wreck site and see how many people 

are hurt. 

Dr. FOLSE. Correct. 

Mr. Davis. Right. Surveyors used that as a part of their review. 

It is part of the things that they look at. They do look at medical 

records, and they do have interviews with the patients and with 

the families and with the staff, and they do have observation. 

Senator BREAUX. Where does that MDS go? 

Dr. FOLSE. If somebody has a cavity—the new question says, 

‘‘Does the resident have a cavity?’’ If they check ‘‘Yes,’’ that goes 

onto the care plan. Once it is on the care plan, they are supposed 

to refer that patient to a dentist or get appropriate care. 

That is actually the way that it is supposed to happen now. The 

problem has been in the actual assessments. We have not had 

enough training to get those done correctly, and where I found 40 

percent of my patients had a ‘‘Yes’’ trigger to the gum disease question, we found across the country out of 3.6 million MDS’s 0.8 percent that were being triggered. So we were missing 39.2 percent of 

the population, according to my records. 

Once that got exposed to CMS, they did make a commitment to 

us and to you to get the new questions and also to put in a quality 

indicator for oral health, which means not only will that information be used at the nursing home level; they receive all of those 

50

data electronically, and if an individual facility would have, say, 

greater than 60 percent gum disease, or they would report less 

than 20 percent gum disease, it would trigger the quality indicator 

for oral health, which would let the surveyors inspect specifically 

for oral health issues. 

Right now, the MDS questions are not tied to a quality indicator, 

so you can check them all of or you can check none of them off, 

and no survey question will come because of the MDS questions. 

So we are changing that. 

Senator BREAUX. My next question was who makes that assessment. When you are admitting someone into a nursing home, is it 

a registered nurse, a practical nurse? Is it just an administrator 

who is on duty that night, who takes a look at the patient and says 

‘‘Yes’’ or ‘‘No’’? 

Dr. FOLSE. In my facility, it is a range. Some facilities have licensed practical nurses do it; some have RN’s do it. I have one facility—I do not go there anymore—where the social director was 

doing it, which was not that appropriate. 

Having the training to get them up-to-speed will help. I think the 

way that we handled that broad case was ‘‘This is normal’’ and 

‘‘This is abnormal.’’ If it is abnormal, you check it, and you refer 

it. We tried to make it real simple, get out the big dental terms—

that is not going to work. 

The problem with the personnel who are doing it now is that 

every time they check this stuff off, they have to refer, and there 

is no infrastructure to refer them to. So it is a round-robin thing. 

Senator BREAUX. Dr. Musher? 

Mr. Musher. Yes, just a couple of comments. One, I can assure 

you that the MDS is taken very seriously in the nursing home, but 

I think it is more of the stick than the carrot is what you are hearing, and it is also data. I think what everybody is saying—and usually in facilities, it is an LPN, licensed practical nurse, not usually 

RN level, who is filling out this information—it is supposed to point 

out where we have concerns or problems to then lead into other 

things. It used to lead into what we called the RAPs, which were 

resident assessment protocols, or guidelines or other things—in 

other words, there may be a problem, how do we now approach 

that. 

I think that is good, but I think what everybody is saying is that 

if it just becomes filling out the form and moving on, then we really 

have not accomplished what we need to accomplish. What we need 

to do is use that form as a guide, if you will, or a screen to say 

that we may have some problems, but we need to give the individual, whether it is the nurse or the other individuals in the facility, the education and the means to then go to the next step—because normally, as you are pointing out—and I have been pretty 

fortunate in most of my facilities to have dentists and dentistry 

available—but if there is a problem, I usually get the call. You are 

absolutely right—sometimes it is very frustrating to sit there and 

say well, I think there may be an abscess or a problem, I know the 

best treatment for an abscess is to take care of it, not just to treat 

with antibiotics—how do we then get to the next step? 

Dr. FOLSE. I actually as the dental director in my facilities do the 

MDS for them, and that is one reason why I really like the dental 

51

director model, because I am part of that process, I am part of the 

team. 

Senator BREAUX. Yes, Daniel? 

Mr. Perry. Thank you, Senator. 

On one level, obviously, what we are talking about is the deplorable state of oral health in America, especially for our seniors. But 

just beneath the surface are two threads that are coming together. 

One is the thread of ageism which is endemic throughout the 

American health care system at all levels, where older patients 

tend to get fewer preventive treatments, less screening, fewer 

interventions than younger people would; and on the other end— and this, too, is part of ageism in our health care—is the failure 

of our professional health education schools to be able to provide 

some access to geriatric content for everyone who passes through 

them. 

For those on the committee who may not know it, Senator 

Breaux has taken the leadership on both of these, and you and 

your staff are to be commended for full-scale hearings within the 

last 18 months, both on the shortage of academic training in geriatrics and on ageism. 

I cannot offer today a simple solution to ageism, because it is 

part of our society; it is part of the fabric of who we are, and it 

has terrible effects on older people in health care. We ought to 

bring attention to it as you have been doing, Senator. 

On the issue of greater envelopment of health professionals in 

their training in geriatrics, we can do something about that, and 

I am urging you and your staff to look at what we might do 

through HRSA to improve professional health education with geriatric content and most promising to create some department-level 

centers in our academic health centers where not only physicians 

and nurses and pharmacists, but dentists and all allied health professions, have to rotate and receive some of the basics in good geriatric care before they are out treating a patient population that increasingly is 50 percent age 60 and older in this country. 

Senator BREAUX. I think that is a helpful suggestion, and I think 

we have heard a number of them. I am trying to figure out, if you 

had the ability to write a recommendation to the Congress and to 

the U.S. Senate as to how we can improve the quality of dental 

care for our Nation’s elderly. I have heard the suggestion of the 

greater use of dental hygienists because of the shortage of dentists 

in many areas. I have heard the suggestion of trying to increase 

Medicaid coverage for the aged, blind, and disabled, at least move 

in that area with a limited amount of money. 

Are there other suggestions that may be appropriate that we 

have not put down? 

Paula. 

Dr. FRIEDMAN. Thank you, Senator. 

I have four recommendations that, with your permission, I would 

like to read into the record. ‘‘One, broaden grantee eligibility for geriatric training programs. 

Dental education institutions currently may only compete for geriatric education center grants. ADEA recommends that grantee criteria be revised to include dental education institutions as the responsible applicant for the geriatric training for physicians, denVerDate 0ct 09 2002 11:50 Jan 13, 2004 Jkt 000000 PO 00000 Frm 00055 Fmt 6633 Sfmt 6633 C:\DOCS\91118.TXT SAGING1 PsN: JOYCE
52

tists, and behavioral/mental health professionals program. We further recommend that the criteria be broadened so that faculty 

members employed by U.S. dental schools are eligible to compete 

for geriatric academic career awards, which are currently limited 

only to physicians.’’ While I certainly agree that we do not need to 

train a huge cohort of specialists, as you indicated earlier, we need 

to train enough to, as we call it, train the trainers, so that they 

can train general dentists and dental students. 

‘‘No. 2, authorize a new geriatric dentistry residency training 

program. ADEA recommends that a new Federal grant program 

modeled on the general and pediatric dentistry residency programs 

be authorized by Congress to prepare the dental workforce to meet 

the growing needs of an aging population.’’ This might be a component of an existing general dentistry training program or indeed a 

second year added onto a 1-year training program in general dentistry with emphasis on geriatrics. 

‘‘No. 3, authorize a new NIH loan repayment program for research on the elderly and other special needs populations.’’ I think 

that is self-explanatory. 

‘‘No. 4 and finally’’—I believe this fourth one encompasses both 

an access issue and the fiscal piece that we all agree is an important component of geriatric oral health care, and that is ‘‘authorize 

a new reimbursement program for elderly dental care at academic 

dental institutions. Dental schools and their satellite clinics provide 

a significant amount of oral health care to the elderly. We are considered the safety net for people with limited fiscal resources. We 

cannot expand services beyond what is being done if Federal assistance is not made available to assist in paying for unreimbursed 

care.’’

Dr. Folse talked about the large degree that all dental schools 

certainly are providing in terms of unreimbursed care. 

‘‘ADEA urges Congress to authorize a dental reimbursement program for poor elderly obtaining treatment at the Nation’s dental 

education institutions.’’

That certainly could include dental hygiene institutions. For your 

information, Senator—I imagine you know this, but just for the 

record—the fees at dental schools are generally a fraction of fees 

in private offices, so that a relationship with a dental education institution would be by extension a fraction of the cost of a private 

practice program. 

Senator BREAUX. Those are good suggestions, and we would like 

to make sure we get a copy of that and the whole presentation. 

Paul. 

Dr. GLASSMAN. I think that in addition to funding and training 

systems, there needs to be a support system, and let me tell you 

what I mean by that. 

We are just finishing up now a grant program that we have had 

in California. We have been working in eight communities around 

the State where we have had what we call a community-based system that is involved using people that we call dental coordinators. 

They are mostly dental hygienists, actually, who have played this 

role. Their role is to actually act as a liaison between the social 

support agencies that exist in every community that deal with the 

53

special populations we are interested in and the dental professionals. 

They do screening and triage; they get people into dental offices; 

they entice dentists to be willing to say ‘‘Yes’’ when they get a referral. They do preventive education. 

I will give you an example of how it might work. Let us say you 

are a dentist, and you have a busy practice, and your practice is 

pretty full with people who can come in and pay full fare and sit 

in your chair and do not have a lot of complicated medical problems. So someone calls and says, ‘‘My mother has dementia. Can 

I bring her in to see you?’’ You think, well, things are kind of busy, but sure, I want to do 

my part. So the person shows up, and you find that the daughter 

who brings the person in does not really know about their medical 

history or the medications they are taking, and their behavior is 

such that there is just no way you are going to treat them, and you 

spend a frustrating half an hour or 45 minutes trying. 

The next time you get a call like that, what do you think you are 

going to say? You are going to say, ‘‘No, I really cannot do that.’’ Now picture situation No. 2. You have a dental coordinator in the 

community who calls up and says, ‘‘I have just done a screening on 

this individual. I was out to see them. I know your office because 

I have talked with you before, and I know the kinds of things that 

you are able to do in your office, and I think this person would 

work pretty well in your office. When they get there, I am going 

to make sure that you have all the medical history information you 

need, and we are going to take care of the consent issues, because 

I am going to work with the social service agency who knows how 

to get consent.’’ When the person gets there, they are going to have the medical 

history, the consent is going to be taken care of, they are going to 

be matched to the dental office. Now, the chances of that referral 

being successful are infinitely better than the first one. 

So in that kind of program, our 3-year results are now showing 

that people have significantly less dental disease. There are numbers of dentists in these communities who are now willing to say 

yes under the circumstances I just described who were not willing 

to say yes before. In fact, the amount of dental disease in the population we are talking about, the burden of dental disease, the cost 

of providing treatment for that dental disease has gone down to a 

degree that it is more than the salaries that we are paying to these 

dental hygienists who are providing these services. 

So I think there needs to be a support system that goes along 

with funding and training. 

Senator BREAUX. So your suggestion is—are you trying to do this 

in California, or——

Dr. GLASSMAN. We are just finishing up a 3-year demonstration 

and demonstrating the effects of this, and we are showing great results. 

Senator BREAUX. So is there a dental coordinator for seniors? 

Dr. GLASSMAN. We picked eight communities throughout the 

State. We have a dental coordinator who works with social service 

agencies in those communities and plays this role of acting as a liaison between these agencies and the dental community, helps to 

54

bridge the gap, helps to make the kinds of referrals that we talked 

about, does preventive education and preventive programs, does 

screenings and gets people into care. 

Senator BREAUX. A good idea. 

Jim. 

Dr. HARRELL. The only thing that would worry me is that in 

North Carolina, we have a shortage of dental hygienists, so I cannot tell you where you are going to get them—do not take them 

from my office. 

Also on the manpower issue, as I said, we have studied that, and 

the term ‘‘shortage’’ has been used a couple of times. I do not 

know—and there again, the data is kind of squirrely—but I do not 

know that we have a shortage, but we definitely have a maldistribution. 

I think the Surgeon General mentioned diversity of the dental 

work force. The University of North Carolina is starting to give 

preference to students from rural areas, hoping that they will return to rural areas when they graduate, because they tend to go 

to the metropolitan areas. So it is hard to know, but I do not know 

that we definitely have a shortage. 

Senator BREAUX. We have had some good suggestions, and this 

is the first thing that we have ever focused on a particular problem 

area of seniors in terms of a disease. We have held hearing on senior problems with people who were scamming them from an insurance standpoint, people who discriminate against them in the job 

market, actual care and treatment that they get in nursing homes, 

and have looked at alternative means of caring for seniors. But I 

think this is really the first time we have actually had a discussion 

on a particular ailment of seniors that has not been noticed as 

much as it should or treated as adequately as it could be. I think 

it has been very helpful to do this, because this really is sort of a 

silent illness out there that people are ignoring, and it leads to 

much more serious problems, much more expensive problems, and 

a lot of suffering that in many cases is unnecessary in today’s society. 

The question is how do we go about trying to fix it and how do 

we go about trying to solve it. We have gotten some good suggestions on the table, and I would like to see if anybody has any closing comments, perhaps, to help us summarize. 

I want to try to bring the information we get from here to maybe 

do some statements on the floor of the Senate to try to get some 

other Members interested in this, because when you find out that 

most States are not doing a very good job of paying attention to the 

oral health of our Nation’s seniors within their States, it is a serious problem, and it should not go neglected as we have neglected 

it in the past. 

Does anybody have any final suggestions that may be helpful? 

Robert. 

Dr. COLLINS. Thanks, Senator. 

This has been a wonderful hearing. There is an awful lot of information that is out there, and many people around this table and 

others have had an opportunity to contribute to that. I think this 

is one more step in the Surgeon General’s Call to Action booklet 

55

which he kind of modestly talked about today, but I think is increasing the involvement of a larger community of people. 

I had a mentor as I came along in public health who used to talk 

about ERAs of expectation in regard to oral health. The first one, 

which I guess covers a large portion of history, was resignation. 

You had pain, and you just found out a way to deal with it, and 

maybe you had somebody who could relieve it by knocking your 

tooth out. 

We went into a second period of rehabilitation where you had 

dentures available, crude in the beginning, more sophisticated as 

time went on, where people could still expect to lose all their teeth, 

but now they had some sort of replacement. 

The third era, which we are really still in and coming out of as 

a whole is the restorative area. These are the 77 million that you 

are talking about in your question, people who have a lot of complex dentistry who are moving into older age. 

The final era is one of prevention. 

So, we have some conflicts here with people who are in an era 

where they are beginning to expect that a lot of these problems 

that Dr. Folse so nicely illustrated today should not be there—they 

should be prevented. We have research that can go a long way toward pointing the way to do that, yet we have a system that I 

would say in many cases is not even in rehabilitation in terms of 

responding; it is back in resignation. 

So there are lots of ways that we can point forward to the future, 

and I just wanted to underscore my appreciation and support not 

only for what the Surgeon General is doing, because I think that 

is a terrific, terrific booklet, that little green booklet, but also for 

all the Federal agencies, in particular the National Institute of 

Dental and Cranio-Facial Research—yes, it does support a lot of research in universities and across the country and funds most of the 

dental research and is therefore very important, but it also serves 

as probably the principal coordinating center in the Federal infrastructure for oral health and makes it possible, I would say, probably if you go back to the beginning, possible for all of us to be here 

today. 

Thank you. 

Senator BREAUX. Thank you. 

Ms. Heinrich, do you have anything from General Accounting? 

Ms. HEINRICH. I really do appreciate the opportunity to hear all 

of these ideas. It really is very thought-provoking. 

I appreciate your point that there are several ways of focusing 

on this problem, and one question I had was with the focus that 

we have put on prevention with children—fluoridation, for example—do we anticipate that this problem is going to wane in the future? 

A second question—Paul, you have talked about some best practices in California; there might be some in New York also, since 

they got a C-plus—but has there been any effort to identify strategies that really do work in trying to bring better dental care to 

older populations? 

Senator BREAUX. Let me interrupt. I am going to have to take 

off. But Janet, why don’t you all finish up on this question, and let 

me just conclude for my part and thank each and every one of you. 

56

I think it has been very important, and we have gotten some good 

ideas. 

To those who have travelled, thank you, Greg and others who 

have come from other places, for being with us. It was well worth 

your effort as far as I am concerned. I am very appreciative of the 

information that we have been able to learn and the suggestions 

that we have received. 

So I thank you all, and please continue. 

Dr. FOLSE. Before you leave, we thank you very much. [Applause.] 

Dr. GLASSMAN. Just to respond to the question about best practices, yes, I think there are a number of publications and articles 

and lots of information about best practices. The problem is that 

the best practices, the theoretical ones, the ones that have been 

used in demonstration projects, are not widely available and not 

widely used because of the issues we have already identified here— awareness and funding and training. 

So the best practices do exist. The American Association of Geriatric Dentists has a number of publications about guidelines for 

nursing home dental practice. There are guidelines in other areas. 

The next issue of the Journal of Special Care Dentistry is going to 

have the results of an expert panel that we brought together to 

look at prevention in disabled and elderly populations. 

So I think the information is there. The problem is taking that 

information and translating it and getting it into practice is where 

there is a gigantic chasm. 

Ms. HEINRICH. In terms of Senator Breaux’ interest in having 

material that people could speak to, are there some of those that 

would have information about dollar savings or costs that could be 

provided to Members of Congress? 

Dr. GLASSMAN. I am not aware of that. I do not know if others 

are. 

Dr. COLLINS. I pointed out earlier that one of the things in the 

Surgeon General’s report on Oral Health in America is that it 

states in that report the lack of data about both the oral health 

burden and strategies and all those things, and we all wish we had 

numbers about those kinds of things. The numbers are generally 

not available, unfortunately. 

Dr. FOLSE. Dr. Barsley actually did a study in Louisiana for 

Medicaid children where they used some interventions, and there 

were significant savings with just water fluoridation for that population. 

Dr. Barsley. 

Dr. BARSLEY. For children with fluoridation, we showed the parishes or counties that were fluoridated had significant savings over 

the counties that were not. Does that translate to the adult population? I am not sure. 

I would break in and answer one question—I do not see this 

problem waning at all. As people have better teeth and better lives, 

we are going to have a bigger problem. So I do not see any waning 

of the problem in any way at all; it will just continue to grow. 

Ms. HEINRICH. Paul, and then James. 

Dr. GLASSMAN. I just want to emphasize that point, that the 

problem is not going away. We have gone from in our country 20 

57

years ago, I think it was something like 56 percent of people over 

65 being in dentures; now it is down to about 26 and dropping. So 

we are having more and more seniors who are becoming seniors 

with teeth that did not used to have that, and the fact that disease 

for certain groups of children is going away does not really have 

much impact on what happens when people get to be 65 and can 

no longer care for themselves the way they used to and begin to 

take medications and have dry mouth. So I think this is going to 

be a blossoming problem. 

Ms. HEINRICH. Teresa. 

Dr. DOLAN. I would just add that I certainly agree that this problem will not go away. It is a good news/bad news story, because as 

the younger cohorts of adults age, and we have retained their natural teeth—maybe we have had some dental fillings—but we also 

have higher expectations, and we are more vocal about our expectations, I think as those folks become chronically ill and perhaps end 

up in long-term care facilities, the demand for a more appropriate 

level of oral health services will grow, and if anything, the cost associated with that will increase. I think that what is currently a 

silent epidemic will become more prominent. 

Ms. HEINRICH. Go ahead, James. 

Dr. HARRELL. As we have a unique program in North Carolina, 

I will try to get any data on cost-sharing that the ADA has for you. 

I am not sure what we have. 

We do have an interesting program in North Carolina where we 

have physicians apply fluoride varnishes. We are doing studies on 

that, and I do not know the results at this point or whether that 

will be a cost saving or not; we suspect that it will. The problem 

was that by the time these children were seeing a dentist at 2 or 

3 years of age, they already had decay. 

The American Dental Association has been sort of reeling with 

the punches and doing what we can to boost the Medicaid reimbursements or whatever. We are having a Medicaid symposium in 

December, which will hopefully be a small group similar to this 

one, to actually look at the whole system and maybe come up with 

some innovations for that system. 

Also, thinking about Paul’s remarks, we have a van program 

which is mostly a nonprofit organization in North Carolina, but I 

do not want us to overlook the fact that there are multi-millionaires in nursing homes who cannot get care because they have special needs, and they require treatment that they do not have the 

facilities to do—even if they can bring them to my office, I cannot 

do it. So I do not want us to overlook that segment of the population either. 

Ms. HEINRICH. Senator Breaux was beginning to ask all of you 

for recommendations on solutions to this problem, and not all of 

you had a chance to speak, so I would ask if there are other ideas. 

Mr. Musher. Just a couple of points—I guess some things that 

we could do now, not to lighten the big, 10,000-foot view—but there 

are certain initiatives going on now. For example, there is a pain 

initiative. There is a collaborative initiative that CMS is part of 

concerning pain and trying to develop best practices. Certainly oral 

pain problems and syndromes could be better focused on through 

that. 

58

So I think there are certain programs that are going on. The 

American Medical Directors’ Association has created many guidelines. That could certainly be something that would lend itself toward a guideline on how do you approach oral care in the nursing 

home. 

Again, not lightening the access to care, which is what I hear is 

a huge issue, and my frustration, as I mentioned earlier, is trying 

to get a dentist or a dental surgeon or extractions or certain things 

that I may need at some points in time, but I think there are areas 

where we could use some of the systems or some of the approaches 

that are now available to just better point out the need for oral 

care. 

I know that like no other industry—in the nursing home, if you 

focus on something, there is a very good likelihood of it happening, 

especially when you connect it with MDS and other survey issues. 

But I think that a lot of what I am seeing is if we could just get 

the word out that oral care is something that is urgent and important, just like we did several years ago with restraint reduction— there was a huge decrease in restraints once we put it back on the 

providers of services to say this is a huge problem, we need to work 

together to solve that problem—and we did, and I do not think 

there was a huge cost to that. 

So although there are a lot of costs and issues that we have 

talked about that I don’t think lend themselves to that, I do think 

at least some focus on how we would approach oral care in nursing 

homes is important. 

The other point I would like to make—and it is no different from 

what we struggle with in other parts of medicine with our population, and I will use high cholesterol as an example. We do not 

treat everybody who has high cholesterol in the nursing home population because it is risk-benefit and it is quality of life issues. So 

at some points, I think we also have to look at what should we be 

treating and what do we not necessarily have to treat. The Senator 

mentioned earlier about whitening teeth. I am not really worried 

about cosmetic issues in a lot of my patients. I am not sure—and 

I would defer to my dental colleagues—whether I have to worry so 

much about dentures, because I was taught that a lot of my patients could actually gum their food. So I am not sure that dentures are as important as pain, abscess, xerostomia, which I have 

seen huge problems with. So how do we focus—the pain, the abscess, those kinds of things in my severely demented patients are 

a quality of life issue, so I would want to focus on the quality of 

life issue, but I think we have to break down the population, because the nursing home has dementia and end-stage and almost 

palliative types of care, but there are all other subsets of elderly 

in our population. 

Ms. HEINRICH. Yes? 

Dr. BARSLEY. If I could add one thing that I do not think has 

been addressed, or only on the margins, it would be to increase 

interaction and educational interplay between physicians and dentists. 

I used to teach at the medical school and give lectures on dental 

health to medical students. They were amazed at what we brought 

them. Then we would bring them out to our clinic and have them 

59

actually look into each other’s mouths, and they were further 

amazed by what was in the mouth besides the teeth. 

So I think if we start at an early time and broaden that, we 

would be benefited. 

Ms. HEINRICH. Karen. 

Ms. SEALANDER. I think that the mere holding of this forum is 

an important signal that this committee, and hopefully the whole 

Senate, thinks that oral health is important. Hopefully in the future, whenever Senators think of seniors’ general health, they will 

think of oral health as well. 

We know how to prevent the principal oral maladies, and despite 

this proven prevention capacity, we still have this silent epidemic 

of oral disease which disproportionately affects our vulnerable citizens, particularly the elderly. ADH wants to be part of a collaborative solution to the problem of oral health disparities and inadequate access to care. ADHA believes that with the increasing 

number of hygienists, the occupational growth, and with our focus 

on prevention that dental hygienists are well-situated to play an 

important role. 

One specific suggestion that ADHA offers is to ask the committee 

to direct CMS to write to State dental directors, asking them to facilitate the provision of Medicaid oral health services by hygienists, 

specifically to recognize hygienists as Medicaid providers of oral 

health services. Ten States already do recognize hygienists as Medical providers and ADHA would like to see the other 40 States follow suit. 

Ms. HEINRICH. Anyone else? 

Dr. FOLSE. A couple of comments in closing for me. In nursing 

facilities, I think there is an obvious partner there. Some of the efforts that we have made have been along survey issues, and I just 

want to assure you that that is not my focus in my advocacy efforts 

and the work that I do with ADA and special care dentistry. It is 

not about coming in with the hammer; it is about we had that opportunity, so you go there. But at the same time, we are doing all 

kinds of things to help bring that industry up with oral health, 

working with the American Medical Director Association. I and 

special care dentistry for sure are seriously committed to working 

with your industry trying to help in any way that we can. We have 

education programs all day long that we can help you with. 

Your point about not treating everyone is really well-taken. I 

have patients with really bad oral conditions who, because of the 

risk-benefit issues, I say we are not going to be able to take care 

of these patients. So I am with you there—education—we can all 

come to consensus with that. 

Again going back to a foundation medically is the medical necessity of oral services. I still think it is a medical necessity. 

Does anyone have disagreement with that? [No response.] 

So one of the things that we could say from this forum—or can 

we—is that we were all in agreement that oral health services for 

vulnerable adults was medically necessary. 

Are there any nays? I do not see any. OK. My dad was an auctioneer. 

60

Dr. HARRELL. Actually, I would modify that and leave out the ‘‘vulnerable adults.’’ Oral health care is essentially the general 

health for anybody. 

Dr. FOLSE. Thank you. I limit myself unnecessarily sometimes. 

I think in these State budgetary woes that everybody has, if they 

would find their State problem and find some things that they did 

not want to pay for, all they have to do is put a set of lips on it. 

Once you get behind some lips, it does not get any money, so it 

seems like it would help somewhere along the way. 

Personally, I have been involved with this forum, and we have 

to thank Lauren Fuller who behind the scenes has done an awful 

lot of work for the last 3 or 4 months, has taken endless calls from 

Dr. Greg Folse—she probably does not want to hear from me for 

6 months, and even then, I am not sure—but we really thank you 

for your work and your dedication to oral health for elders across 

the country. You have started something here, and it is going to 

be a fun ball to watch. 

Before I let you close this, I want to thank each and every one 

of you again for being here and participating, and those of you in 

the audience who really care about oral health services for our elderly, I thank you for being here also. 

Ms. HEINRICH. Well, I think you did a very nice job of closing. 

I think it is easy to say that you have put information together in 

one place, and yes, it is going to be interesting to see how this 

moves forward. 

Thank you all. 

[Whereupon, at 4:05 p.m., the forum was concluded.] 

(61)

A P P E N D I X 


91118.024
62


91118.025
63


91118.026
64


91118.027
65


91118.028
66


91118.029
67


91118.030
68


91118.031
69


91118.032
70


91118.033
71


91118.034
72


91118.035
73


91118.036
74


91118.037
75


91118.038
76


91118.039
77


91118.040
78


91118.041
79


91118.042
80


91118.043
81


91118.044
82


91118.045
83


91118.046
84


91118.047
85


91118.048
86


91118.049
87


91118.050
88


91118.051
89


91118.052
90


91118.053
91


91118.054
92


91118.055
93


91118.056
94


91118.057
95


91118.058
96


91118.059
97


91118.060
98


91118.061
99


91118.062
100


91118.063
101


91118.064
102


91118.065
103


91118.066
104


91118.067
105


91118.068
106


91118.069
107


91118.070
108


91118.071
109


91118.072
110


91118.073
111


91118.074
112


91118.075
113


91118.076
114


91118.077
115


91118.078
116


91118.079
117


91118.080
118


91118.081
119


91118.082
120


91118.083
121


91118.084
122


91118.085
123


91118.086
124


91118.087
125


91118.088
126


91118.089
127


91118.090
128


91118.091
129


91118.092
130


91118.093
131


91118.094
132


91118.095
133


91118.096
134


91118.097
135


91118.098
136


91118.099
137


91118.100
138


91118.101
139


91118.102
140


91118.103
141


91118.104
142


91118.105
143


91118.106
144


91118.107
145


91118.108
146


91118.109
147


91118.110
148


91118.111
149


91118.112
150


91118.113
151


91118.114
152


91118.115
153

Æ


91118.116